Vol 30, No 6 (2023)
Review Article
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Out-of-hospital cardiac arrest: Do we have to perform coronary angiography?

Wojciech Wańha12, Michalina Kołodziejczak32, Mariusz Kowalewski45, Rafał Januszek6, Łukasz Kuźma7, Miłosz Jaguszewski82, Mariusz Tomaniak92, Szymon Darocha102, Karolina Kupczyńska112, Piotr Dobrowolski122, Agata Tymińska92, Aleksandra Ciepłucha132, Justyna Sokolska142, Agnieszka Kapłon-Cieślicka92, Andrzej Kułach152, Maciej Wybraniec216, Tomasz Roleder171, Mateusz Tajstra18, Klaudiusz Nadolny1920, Tomasz Darocha21, Katarzyna Sierakowska3, Tomasz Pawłowski22, Marek Gierlotka23, Maciej Lesiak13, Krystian Wita16, Robert Gil242, Przemysław Trzeciak18
Pubmed: 37183538
Cardiol J 2023;30(6):1026-1037.

Abstract

Out-of-hospital cardiac arrest (OHCA) remains a leading cause of global mortality, while survivors
are burdened with long-term neurological and cardiovascular complications. OHCA management at
the hospital level remains challenging, due to heterogeneity of OHCA presentation, the critical status of
OHCA patients reaching the return of spontaneous circulation (ROSC), and the demands of post ROSC
treatment. The validity and optimal timing for coronary angiography is one important, yet not fully
defined, component of OHCA management. Guidelines state clear recommendations for coronary angiography
in OHCA patients with shockable rhythms, cardiogenic shock, or in patients with ST-segment
elevation observed in electrocardiography after ROSC. However, there is no established consensus on
the angiographic management in other clinical settings.
While coronary angiography may accelerate the diagnostic and therapeutic process (provided OHCA
was a consequence of coronary artery disease), it might come at the cost of impaired post-resuscitation
care quality due to postponing of intensive care management. The aim of the current statement paper is
to discuss clinical strategies for the management of OHCA including the stratification to invasive procedures
and the rationale behind the risk-benefit ratio of coronary angiography, especially with patients
in critical condition.

interventionAL CARDIOLOGY

review article

Cardiology Journal

2023, Vol. 30, No. 6, 1026–1037

DOI: 10.5603/CJ.a2023.0032

Copyright © 2023 Via Medica

ISSN 1897–5593

eISSN 1898–018X

Out-of-hospital cardiac arrest: Do we have to perform coronary angiography?

Wojciech Wańha*12Michalina Kołodziejczak*13Mariusz Kowalewski45Rafał Januszek6Łukasz Kuźma7Miłosz Jaguszewski18Mariusz Tomaniak19Szymon Darocha110Karolina Kupczyńska111Piotr Dobrowolski112Agata Tymińska19Aleksandra Ciepłucha113Justyna Sokolska114Agnieszka Kapłon-Cieślicka19Andrzej Kułach115Maciej Wybraniec116Tomasz Roleder217Mateusz Tajstra18Klaudiusz Nadolny1920Tomasz Darocha21Katarzyna Sierakowska3Tomasz Pawłowski22Marek Gerlotka23Maciej Lesiak13Krystian Wita16Robert Gil122Przemysław Trzeciak18
1“Club 30”, Polish Cardiac Society, Poland
2Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
3Department of Anesthesiology and Intensive Care, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
4Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Center of Postgraduate Medical Education, Warsaw, Poland
5Thoracic Research Center, Innovative Medical Forum, Collegium Medicum Nicolaus Copernicus University, Bydgoszcz, Poland
6Second Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
7Department of Invasive Cardiology, Medical University of Bialystok, Poland
8First Department of Cardiology, Medical University of Gdansk, Poland
9First Department of Cardiology, Medical University of Warsaw, Poland
10Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education Fryderyk Chopin Hospital in European Health Center Otwock, Poland
11Chair and Department of Cardiology, Medical University of Lodz, Poland
12Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
13First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
14Department of Cardiovascular Imaging, Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
15Department of Cardiology, Medical University of Silesia, Katowice, Poland
16First Department of Cardiology, Medical University of Silesia, Katowice, Poland
17Department of Cardiology, Regional Specialist Hospital in Wroclaw, Poland
18Third Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
19Faculty of Medicine, Katowice School of Technology, Katowice, Poland
20Department of Health Sciences, WSB University, Dabrowa Gornicza, Poland
21Department of Anesthesiology and Intensive Therapy, Medical University of Silesia, Katowice, Poland
22Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Center of Postgraduate Medical Education, Warsaw, Poland
23Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Poland

Address for correspondence: Wojciech Wańha, MD, PhD, Department of Cardiology and Structural Heart Diseases,
Medical University of Silesia, ul. Ziołowa 45, 40–635 Katowice, Poland, tel: +48 32 359 80 00, fax: +48 32 202 87 54,
e-mail: wojciech.wanha@gmail.com

Received: 9.11.2022 Accepted: 15.03.2023 Early publication date: 12.05.2023

*Authors contributed equally to this paper.

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.

The paper was guest edited by Prof. Javier Lopez-Pais

Abstract
Out-of-hospital cardiac arrest (OHCA) remains a leading cause of global mortality, while survivors are burdened with long-term neurological and cardiovascular complications. OHCA management at the hospital level remains challenging, due to heterogeneity of OHCA presentation, the critical status of OHCA patients reaching the return of spontaneous circulation (ROSC), and the demands of post ROSC treatment. The validity and optimal timing for coronary angiography is one important, yet not fully defined, component of OHCA management. Guidelines state clear recommendations for coronary angio­graphy in OHCA patients with shockable rhythms, cardiogenic shock, or in patients with ST-segment elevation observed in electrocardiography after ROSC. However, there is no established consensus on the angiographic management in other clinical settings.
While coronary angiography may accelerate the diagnostic and therapeutic process (provided OHCA was a consequence of coronary artery disease), it might come at the cost of impaired post-resuscitation care quality due to postponing of intensive care management. The aim of the current statement paper is to discuss clinical strategies for the management of OHCA including the stratification to invasive procedures and the rationale behind the risk-benefit ratio of coronary angiography, especially with patients in critical condition. (Cardiol J 2023; 30, 6: 1026–1037)
Key words: out-of-hospital cardiac arrest, coronary angiography

Introduction

Recommendations for performing coronary angiography (CAG) in patients admitted after out-of-hospital cardiac arrest (OHCA) are limited to patients presenting with shockable rhythm, cardiogenic shock, or in patients with ST-segment elevation myocardial infarction (STEMI) on electrocardiography (ECG) after a return of spontaneous circulation (ROSC) (Table 1) [1–6]. As the majority of sudden cardiac arrests (CAs) are caused by non-shockable rhythms without underlying acute coronary lesion, they lack a clear indication for CAG [7, 8]. The 2021 update of European Resuscitation Council (ERC) and European Society of Intensive Care Medicine (ESICM) guidelines describe post-resuscitation care outlining emergent CAG strategy in the context of ST-elevation (STE) prevalence, as well as in patients without STE on the ECG but at a high probability of acute coronary occlusion [4]. The 2020 European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent STE recommend considering delayed, as opposed to immediate, CAG among hemodynamically stable patients without STE who were successfully resuscitated after OHCA [3]. The recommendations are to be altered by ongoing trials focusing on more detailed clinical settings to further define the possible benefit of an early invasive approach.

Table 1. Guideline recommendations for coronary angioplasty in cardiac arrest patients.

Guideline

Coronary angioplasty

Class, level

2017 ESC Guidelines for the management of acute myocardial infarction with ST-segment elevation [1]

A primary PCI strategy is recommended in patients with resuscitated CA and an ECG consistent with STEMI

I, B

In cases without STE on post-resuscitation ECG but with a high suspicion of ongoing myocardial ischemia, urgent CAG should be done within 2 h after a quick evaluation to exclude non-coronary causes. In all cases, the decision to perform urgent CAG should take into account factors associated with poor neurological outcome

IIa, C

2017 AHA/ACC/HRS Guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death [2]

In patients who have recovered from unexplained sudden CA, CT or invasive CAG is useful to confirm the presence or absence of ischemic heart disease and guide decisions for myocardial revascularization

I, C-EO

Quickly identifying and treating patients with OHCA related to acute coronary occlusion is associated with improved survival and better functional recovery

NA

Coronary occlusion as a cause of CA is not reliably predicted by clinical and ECG findings, and emergency CAG should be considered (rather than later in the hospital stay or not at all) for unstable patients with a suspected cardiac etiology regardless of whether the patient is comatose or awake

I, B-NR

2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [3]

The management of patients presenting with resuscitated CA and concomitant NSTE-ACS needs to be individualized according to their hemodynamic and neurological status. In comatose survivors, ECG should be performed immediately for further evaluation of differential diagnoses

NA

Delayed as opposed to immediate CAG should be considered among hemodynamically stable patients without STE successfully resuscitated after OHCA

IIa, B

2021 ACC/AHA/SCAI Guideline for coronary artery revascularization [5]

In patients with VF, polymorphic VT, or CA, revascularization of significant CAD (with CABG or PCI) is recommended to improve survival

I, B-NR

2021 ERC and ESICM Guidelines: post- -resuscitation care [4]

In patients with ROSC after OHCA without STE on the ECG, emergent cardiac catheterization laboratory evaluation should be considered if there is an estimated high probability of acute coronary occlusion (e.g., patients with hemodynamic and/or electrical instability)

NA

2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death [6]

In electrically unstable patients after sudden CA, with suspicion of ongoing myocardial ischemia, a CAG is indicated

I, C

Urgent CAG is recommended for patients presenting with STEMI

I

REFERENCE FOR GUIDELINE RECOMMENDATIONS

ACC/AHA/HRS/SCAI Guidelines

Classes (STRENGTH) of Recommendation

Class I (STRONG) Benefit >>> Risk

Class IIa (MODERATE) Benefit >> Risk

Class IIb (WEAK) Benefit > Risk

Class III: No Benefit (WEAK) Benefit = Risk

Class III: Harm (STRONG) Risk > Benefit

Level (QUALITY) of Evidence

Level A

High-quality evidence* from more than 1 RCT

Meta-analyses of high-quality RCTs

One or more RCTs corroborated by high-quality registry studies

Level B-R (Randomized)

Moderate-quality evidence* from 1 or more RCTs

Meta-analyses of moderate-quality RCTs

Level B-NR (Nonrandomized)

— Moderate-quality evidence* from 1 or more well-designed, well-executed nonrandomized studies, observational studies, or registry studies

— Meta-analyses of such studies

Level C-LD (Limited Data)

Randomized or nonrandomized observational or registry studies with limitations of design or execution

— Meta-analyses of such studies

Physiological or mechanistic studies in human subjects

Level C-EO (Expert Opinion)

Consensus of expert opinion based on clinical experience

ESC Guidelines

Classes of Recommendation

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/ /efficacy of a procedure or treatment

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy

Class IIb: Usefulness/efficacy is less well established by evidence/opinion

Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful

Levels of Evidence

Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses of such studies

Level of Evidence B: Data derived from one or more randomized trials or meta-analysis of such studies. Data derived from one or more non-randomized trials or meta-analysis of such studies

Level of Evidence C: Non randomized observational studies with limitations in design or execution or metanalysis of such studies. Consensus opinion of experts based on clinical experience

Etiology of OHCA

The timeline of OHCA management implies a number of pitfalls, and long-term clinical outcomes that are strictly determined by the promptness and quality of the measures undertaken during the initial period after CA. Sudden CA is characterized by a relatively low prevalence among the general population, challenging the development of an accurate individual risk prediction tool. It is particularly difficult among individuals without premonitory symptoms who remain at risk of sudden CAs as their first cardiac event [9–12]. Ischemic heart disease remains a dominant contributor to sudden CAs, albeit cardiomyopathies associated with myocardial fibrosis and left ventricular hypertrophy also significantly increases its prevalence [11]. Moreover, ischemic heart disease is less frequent among younger populations (where genetic structural disorders and cardiac channelopathies, myocarditis, and congenital heart disease are more widespread), but its prevalence increases with age which allows for the atherosclerotic burden to build up [13].

ST-elevation on ECG

Since the OHCA population is so diverse, it is necessary to implement a differential diagnosis as soon as possible after stabilizing the patient’s condition. This allows for the ROSC status to be reached or maintained and the patient’s prognosis to be improved. The simultaneous implementation of various diagnostic elements enables a comprehensive assessment of the patient’s condition and the determination of therapeutic priorities. One of the fastest, widely available, and cost-effective tools is the ECG, which is used in the initial stage of patient management before reaching ROSC. ECG is of additional importance in the context of high positive predictive value of STE for acute coronary lesions causing CA (8596%), and OHCA being the first manifestation of coronary artery disease (CAD) [14–17]. International guidelines for decades gave strong recommendations on the timely management of patients presenting with STE on post-ROSC ECG. Urgent (≤ 2 h) angiography with primary percutaneous coronary intervention (PCI) was the strategy of choice in this population [1]. As a consequence, for over 12 years (2000 vs. 2012) CAG and PCI were performed more frequently in patients after post-ROSC STEMI of ventricular tachycardia or ventricular fibrillation (VT/VF) of OHCA origin (53.7% vs. 87.2% and 29.7% vs. 77.3%, respectively). Additionally, patient survival to discharge has also improved (59.2% vs. 74.3%) [18, 19] over this period.

Non-ST-elevation myocardial infarction

The potential benefit or harm of urgent CAG in patients without STE is still a subject of debate. A question on the proper selection of patients for early CAG strategy is particularly important. An advantage of CAG in OHCA patients could only be present in the group with significant stenosis in the coronary artery who received PCI for reversing ongoing ischemia [20]. Thus, it is conceivable that the potential benefit of emergency CAG in patients with post-ROSC depends heavily on the presence of significant stenosis in the coronary arteries.

While the observational and registry data suggest improved survival with early CAG [21–24], randomized studies showed no such benefit when comparing emergency CAG with a delayed strategy [8, 25]. This was confirmed by a recent meta-analysis showing no difference in early vs. non-early CAG in terms of mortality, neurological status, and rate of PCI during 30 days among patients with OHCA without STE [26].

The obstructive coronary atherosclerosis and acute thrombotic occlusions in the post-OHCA population are not uncommon but can vary between different subgroups. In the PROCAT registry [16], the reported prevalence of acute CAD was 58%, while in TOMAHAWK randomized trial [25], authors claimed a 40% prevalence of coronary culprit lesions. In the EMERGE trial [8], the latest published randomized study, significant CAD was found only in 49.7% of patients. The highest number of CAD post-OHCA, reaching 65%, was observed in COACT trial [27]; however, patients with non-shockable rhythm were excluded from randomization. Other studies conducted in patients with CA without STE who underwent CAG report approximately 25% acute occlusions and nearly 60% significant obstructive lesions [28]. Despite the high prevalence of CAD in OHCA patients without STE, a high burden of comorbidities, including intracranial bleeding, is present in this population [29, 30], suggesting that the cause of CA in this setting may be due to non-cardiac causes. Additionally, the ECG changes originating from a brain injury can be present and mimic myocardial ischemia (widespread giant T-wave inversions, QT prolongation, bradycardia, STE/ST-depression, increased U wave amplitude) [31, 32]. Therefore, before the final decision to perform CAG, unfavorable features that potentially affect the survival of complicated OHCA patients should be assessed, preferably after consultation by a multidisciplinary team. In this population, the outcomes are driven by neurological complications or multiorgan failure, resulting in a 10-fold higher mortality rate compared to non–CA patients with STE [33]. Faced with numerous features indicating multiorgan and irreversible ischemia, the incremental benefit of restoring coronary perfusion would be marginal and clinically insignificant.

To address some of these controversies, a number of studies were conducted on patients without STE in order to quantify the potential role of CAG and intervention (Table 2) [8, 25, 27, 34–37]. The COACT trial [25] showed no significant difference in clinical outcomes after 1-year follow-up in OHCA patients with a shockable rhythm in the absence of STE treated with both strategies. These results suggested that CAG can be delayed until neurologic recovery. The data from the TOMAHAWK trial [23] point toward the lack of benefit of early CAG in clinical outcomes such as survival, bleeding, stroke, or renal failure. Moreover, the authors noted a slight increase in the composite outcome of death and severe neurologic deficit in the group treated with immediate CAG. Additionally, the most recent randomized clinical trial showed that a strategy of emergency CAG was not better than a strategy of delayed CAG with respect to 180-day survival rate and neurologic sequelae [8]. Immediate CAG may be warranted for a specific subgroup of OHCA patients with no significant comorbidities who are hemodynamically unstable and have an unknown cause of arrest at the time of admission, but who are likely to regain consciousness. These patients were excluded from previous trials, but are still at a high likelihood of having underlying CAD.

Table 2. Studies in out-of-hospital cardiac arrest with patients presenting with non-ST-segment elevation myocardial infarction.

Study

Years of enrollment
Type of study

Number
of patients

Inclusion criteria

Arms

Main outcomes
assessed
(follow-up)

Timing
of coronary
angiography

Outcomes

ARREST [34]

02.2018–09.2020 (planned)
RCT

860
patients (planned)

OHCA with ROSC and absence of STE on ECG
Absence of non-
-cardiac cause (trauma, drowning, suicide, drug overdose)
Prognostication is to be delayed in trial
patients until ≥ 72 h post arrest

Direct transfer
to CA center
vs.
Current standard of care (geographically closest ED)

All-cause mortality (30 days,
3, 6, 12 months)
Cerebral performance category score (30 days,
3 months)
Modified Rankin Score (30 days,
3 months)
EQ-5D-5L QoL
(30 days)

NA

NA

COACT [27, 35] [NTR4973]

01.2015–07.2018
A prespecified
analysis of RCT

552
patients

OHCA with a shockable rhythm who reached ROSC in the absence of STEMI

Immediate CAG
vs.
Delayed CAG

Survival, MI, revascularization, ICD shock, QoL, hospitalization for heart failure, and the composite of death or MI or revascularization (1 year)

2.1 h (IQR 1.52.8) vs. 121.4 h
(IQR 50.4
201.4)

No significant difference in clinical outcomes at 1 year between the two strategies
CAG can be delayed until after neurologic recovery without affecting outcomes

EMERGE [8]
[NCT02876458]

01.2017–11.2020
RCT

279
patients

OHCA with ROSC, without an obvious non-cardiac cause
of arrest
No evidence of STE on postresuscitation ECG

Emergency CAG
vs.
Delayed CAG
(sooner
than 48 to 96 h)

180-day survival rate with no or minimal neurologic sequelae

2 h (IQR 23) vs. 65.5 h
(IQR 40.8
74.8)

Survival rate at 180 days (emergency CAG, 36.2% [51 of 141] vs. delayed CAG, 33.3%
[46 of 138];
HR 0.86;
95% CI 0.64
1.15;
p
= 0.31)

PEARL [NCT02387398] [50]

01.2016–10.2018
RCT

99
patients

Successfully resuscitated and comatose after OHCA, without regard for initial rhythm
Suspected cardiac
etiology for their
sudden CA
ECG demonstrated no STE or new LBBB

Early CAG (within 120 min of arrival at the PCI-capable center)
vs.
No early CAG (no CAG within 6 h of hospital arrival)

A composite of efficacy and safety measurements (efficacy measures of survival to discharge and favorable neurologic status at discharge and echocardiographic measures) within 24 h of admission
Secondary end points:
prevalence of acute coronary occlusion, survival and favorable neurologic function (30 ± 15 and 180 ± 30 days after hospital discharge)
LVEF, and regional wall motion scores (at hospital discharge and 180 ± 30 days after discharge)

1.5 h (IQR 0.8 to 2.0) vs. 2.5 days (IQR 0.6 to 7.2) 48% of patients had CAG

The primary end point 55.1% early CAG vs. 46.0% no early CAG
Death at 6 months (early CAG vs. no early CAG; HR 0.93; 95% CI 0.55
1.95; p = 0.77)

PROCAT II [51]

01.2004–12.2013
Registry

695
patients

OHCA patients with an emergent CAG
No evidence of STE on the post-resuscitation ECG

Not randomized
Successful PCI
vs.
No culprit lesion

The best level on the cerebral performance category scale (at hospital discharge)

NA

~30% of OHCA patients without STE had a culprit coronary lesion requiring PCI
Emergent PCI was associated with a nearly 2-fold increase in the rate of cerebral performance category
An initial shockable rhythm was the sole independent indicator for PCI requirement

TOMAHAWK [26] [NCT02750462]

11.2016–09.2019
RCT

554
patients

Successfully resuscitated OHCA of possible coronary origin
No evidence of STE on postresuscitation ECG
Both shockable and nonshockable arrest rhythms

Immediate CAG
vs.
Initial intensive care assessment with delayed or selective CAG

Death from any cause (30 days)
A composite of death from any cause or severe neurologic deficit (30 days)

2.9 h (IQR 2.23.9) vs. 46.9 h (IQR 26.1116.6)*

Death: 54.0% vs. 46.0% (HR 1.28; 95% CI 1.001.63; p = 0.06)
The composite of death or severe neurologic deficit: 64.3% vs. 55.6% (RR 1.16; 95% CI 1.00
1.34)
Comparable values for peak troponin release, the moderate or severe bleeding, stroke, and RRT

The choice to perform emergency CAG post-ROSC should also consider issues related to poor neurological outcome. The clear-cut benefit of immediate CAG in other settings is still a matter of debate. Coronary angiography holds both potential risks and benefits that, could either improve a patient’s condition or result in a greater burden for complications. This would depend on the underlying cause of the OHCA and concomitant medical issues (Table 3). Urgent CAG may increase the risk of bleeding and procedural complications, especially in unstable and neurologically compromised patients after an extensive resuscitation, which can further decline chances of survival. On the other hand, primary revascularization of coronary occlusions increases myocardial viability, securing better cardiovascular and perfusion stability that might be of a paramount importance in patients with severe acute myocardial dysfunction. In cases where coronary revascularization is not feasible, the exclusion of underlying CAD can provide valuable insights into differential diagnosis of complicated OHCA cases and optimal pharmacological management. Some investigators believe that reorganization and facilitation of OHCA management could offer significant clinical benefit. The ongoing ARREST [34] trial assesses the impact of the facilitated organization of OHCA management (direct transfer to CA center) in patients without STE vs. the current standard of care. Notably, a consulting cardiologist should be aware of potential neurological compromise and questionable survival benefit when qualifying to CAG. As reported in the study by Laver et al. [38], regardless of initial rhythm or ECG findings, the main reason for death in patients with OHCA is due to anoxic brain injury and, secondly, due to a refractory post-arrest shock and multi-organ failure. It was also confirmed in the COACT trial [27], which demonstrated that neurological condition was the cause of death in more than 70% of cases.

Table 3. Benefits and risks of revascularization in out-of-hospital cardiac arrest patients.

Benefits

Risks

High prevalence of coronary artery occlusions despite the absence of ST-elevation on the first acute electrocardiography

Highly unstable patients at a high risk of coronary angiography complications (a need to identify patient sthat would benefit from the procedure by detection of other potential treatable causes of the arrest, provision of clinical optimization prior to angiography)

Exclusion of coronary artery disease leading to facilitated differential diagnosis towards alternative etiology of cardiac arrest

Procedure-related adverse events

Withdrawal of potentially harmful antithrombotic treatment in case of coronary artery disease exclusion

Suboptimal care during peri-catheterization period (intensive care management included)

Treatment algorithm for management of OHCA

While response time and quality of care in the “chain of survival” predominantly affect survival of OHCA patients, an access to certain specific treatments, such as early activation of emergency medical services and resuscitation or advanced post-admission care with a focus on treating the underlying cause of OHCA, improves chances of recovery [39–41]. Upon OHCA patient arrival to a hospital emergency department, rapid and detailed assessment is required to develop a tailored treatment plan to be implemented in the department specializing in intensive management (Central illustration) [28, 42, 43]. Notably, 80% of OHCA patients admitted alive to the hospital are unconscious [44, 45]. Considering the high frequency of CAD as a cause of OHCA, interventional cardiologists are consulted frequently to consider CAG. Although emergency CAG is recommended in post-resuscitation STEMI patients, there is a common belief among physicians about the alleged benefit of CAG in OHCA patients without STE, which is not supported by current evidence.

Central illustration. Proposed algorithm for coronary catheterization. Based on Rab et al. [28], Jentzer et al. [42], and Kelly et al. [43]; I. Exclude non-cardiac reasons for arrest = (acute respiratory failure, non-cardiogenic shock) by surgical management of trauma, neurosurgical or vascular patients, and/or brain and chest computed tomography--scans with subsequent thrombectomy of cerebral arteries, pneumothorax dressing, etc.; ACO — acute coronary occlusion; ALS — advanced life support; CABG — coronary artery bypass grafting; CAD — coronary artery disease; CICU — cardiac intensive care unit; CPR — cardiopulmonary resuscitation; ECG — electrocardiography; ECLS — extracorporal life support; ED — emergency department; ETCO2 — end tidal carbon dioxide; ICU — intensive care unit; LBBB — left bundle branch block; LV — left ventricle; OHCA — out-of-hospital cardiac arrest; PCI — percutaneous coronary intervention; ROSC — return of spontaneous circulation; STE — ST-elevation; TTM — targeted temperature management; VF — ventricular fibrillation; VT — ventricular tachycardia.

Timely introduction of post-ROSC care, including admission to cardiac intensive care unit (CICU) or intensive care unit (ICU), targeted temperature management, vital-organ support, and treatment of the underlying cause of the arrest improves neurological outcomes that are detrimental drivers of survival and quality of life after hospital discharge, with studies reporting the majority of non-survivors dying of neurologic complications after the CA [27, 38, 46–48]. Therefore, any procedures delaying the initiation of post-ROSC management should be accounting for the potential benefit-risk ratio of an individual patient. This, depends on the center’s organization and team leader approach for a specific clinical presentation, that usually takes one of two forms ordering advanced imaging procedures, and consults from the level of the emergency department, prior to the admission to CICCU/ICU, or timely admission to CICU/ICU, where additional procedures are conducted after a period of initial stabilization of the condition and initiation of post-ROSC care. The clinical condition of the patient and OHCA presentation remains a significant driver for diverse steps of treatment management. Unclear presentation requires the execution of not only general post-ROSC care but also an introduction of differential diagnosis and personalized management. Any concomitant conditions that contributed to OHCA or has complicated its presentation require urgent medical attention and are commonly prioritized in treatment plan development. This includes, but is not limited to, the treatment of reversible arrest causes (acute respiratory failure, non-cardiogenic shock), surgical management of trauma, neurosurgical or vascular patients, coronary angiography and/or brain and chest computed tomography scans with subsequent thrombectomy of cerebral arteries, pneumothorax dressing, etc. Despite delaying patient admission to the ICU, these procedures can provide vital clinical reserves for stabilizing and subsequently improving a patients’ condition and future outcomes.

Closing remarks

The facilitation and individualization of OHCA management remain a pivotal point of focus to assert improvement of clinical outcomes. With patients facing poor survival and requiring timely neurological- or cardiovascular-oriented management, there is an urgent need for data, especially in patients without STE who could benefit from either immediate or delayed angiography.

Conflict of interest: None declared

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